This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Friday, February 06, 2009

More tales from Honora in Uganda

Some more stories from Honora Englander, a young American doctor in Uganda:

It has been a good week here – I've settled in well, and the shared routine and language of medicine, ward rounds, and patient care between the US and East Africa makes it surprisingly easy to connect with new people and fit into a familiar routine.

The structure of the day is where the familiarity ends, as the cases on the wards are markedly different from what we see at home. I am seeing cases of brucellosis, TB peritonitis with lymphatic enlargement enough to cause surgical bowel obstruction, severe malaria causing whopping cardiac murmurs, and profound malnutrition in the setting of chronic infection. I've been quite impressed with the students and the residents – eager, smart, and curious. And it is such a pleasure to get to learn together and to get to know them.

Yesterday I invited the students on my ward team to lunch after rounds. 8 in total – 1 man and 7 women – joined me for lunch just off campus. Initially conversation jumped from hobbies (they enjoy novels, tennis, the TV series "24," and laughing) to family to Obama and Africa's high hopes for him. The women uniformly described Obama as both inspiring and very handsome. They laughed when I heartily agreed, and one woman quickly offered me marriage to her brother, who looks "just like him."

Conversation turned to questions about details of medical education in the US, presumably in part because so many of them hope to someday practice outside of Uganda. "How many years of school it takes to be a doctor in the US?" "What the training is like?" "What diseases do you see? Do you see much HIV?" One particularly sharp young woman, Marjorie, asked me my thoughts on why HIV is so rampant here. Though national statistics quote 6% prevalence, my estimate is that at our referral center, roughly half of the patients on the wards have HIV.

"Why has AIDS spread so much in Uganda?" she wanted to know. "What do you do differently in your country that you see so few cases?" We were towards the end of lunch, and the group had a 2PM lecture, so Marjorie and I continued as we walked back towards campus. Briefly, we touched on politics and policy, education and culture. "Do you think literacy level could affect someone's risk of HIV?" she asked.

We talked about the role of women in society, and she described what I have heard expressed repeatedly in different ways both here, in Kampala, and in Eldoret; if a man marries a woman, his father and brothers also have the right to "use the woman." She wondered if teaching people about the risks associated with this practice would help; I wondered if this is so much a part of people's culture, can society "teach it" out of them? We talked a bit about prevalence, and I was amazed to hear Marjorie quote HIV prevalence of 70% amongst students at MUST (Mbarara University of Science and Technology). I couldn't (and still don't) believe the numbers are nearly that high, but she quoted a recent study whereby they screened blood donors from the university. After that, the newspapers reported 70% of students are infected. When I asked if she knows students who are open about their HIV status, she reported: "Definitely not. Too much stigma." But she explained that in the dorms she sometimes sees ARV pill pack wrappers in the trash, and that she knows that there are students who hide their HIV status.

I explored some of these ideas further with a group of students in the first Art of Medicine today. Earlier in the week I was introduced to Dr. Maling, a faculty member in Psychiatry who is getting a masters in medical education and who is doing his thesis about stress amongst healthcare workers. We share common interests, and he was eager to have me hold Art of Medicine discussions – case-based discussions focusing on the nonclinical aspects of doctoring – with his psychiatry students. He also asked that I hold a session with his own team of doctors, nurses and support staff. During today's Art of Medicine we talked about the case of a student who feared getting a needle stick from a delirious patient with HIV. Many of the themes that I have heard in the past when discussing this case surfaced. Student expressed worry that patients might be vindictive towards doctors and try to infect them, they said that caring for dying patients with HIV reminds them of their own family members who have died from HIV ("every family has someone who has died of HIV"), and described a collective sense that there is tremendous stigma against HIV, both within and outside of the medical community.

New in this discussion compared with past years was that students talked about the role of the church, both in promoting education and affecting stigma. Some students blamed the church for stigma, explaining Uganda is a religious country, and that the church suggests that people with HIV are sinners. They explained that the church supports "A" and "B" (abstinence and "be faithful") but not "C" (condoms). This is so embedded in the culture that people are ashamed to buy condoms. One student said that if he were to buy condoms, people would think he had HIV or was very promiscuous. Other students argued in support of the church's stance, saying that the church has a role to promote morals, and that it is their duty to speak out against premarital sex. They felt it was okay to ignore or even shun condom use because a married couple that is faithful won't get HIV. It was a hot debate.

At one point, I started to get uneasy, watching the passionate opinions in the room and remembering the quote of 70%. Though the number is likely exaggerated, certainly there might be HIV+ students in the room who could feel uneasy. In general, I try to anticipate this by introducing each session with notice that the conversation can often engender strong feelings, and I try to give people the choice to opt in or out, but one never knows for sure what people are feeling. I asked the students what they thought about the 70% statistic that I had been quoted, and the room erupted with shouts of disagreement. They too had heard this number before, and most vehemently disagreed with it. One student explained – "That is the press. A dog might bight a man, but the press will report that a man bit a dog to sell papers." One woman, however, pointed out that the strong reaction in the group suggested fear amongst the students.

Numbers aside, we continued talking, assuming and acknowledging that HIV exists within the student community. This shifted the tone some, and students were slightly less confident about their assumptions of right and wrong, culpable and innocent. One person raised a comparison between having HIV and malaria, and I challenged them to consider how it might be if HIV shared no more stigma than malaria. They agreed with me when I posited that anyone is at risk for HIV, that we've all made choices we regret or had lapses in best judgment, and that their family members and friends who have died are no more sinful than those who have suffered from malaria. Still, as they continued talking, they quickly switched back to language of blame, suggesting that it was a stretch to let go of the stigma that is so deeply embedded in their community.

Uganda has been praised as a leader in Africa in its efforts to raise awareness and be forthcoming about HIV/AIDS. When, as late as the early 2000s the South African government was denying that HIV causes AIDS, Uganda was promoting AIDS education throughout the country. And yet still, on the wards we say NYY (No-Yes-Yes for HIV+, as compared to NYN (HIV-) or NYU (unknown serostatus)) and nobody uses the word HIV with patients. Still, the stigma is so entrenched. I feel hopeful by the voices that respond openly when asked to question this, and I continue to believe that there is a role for open discussion of these issues, both as a way of changing attitudes and improving health care here.

Though all of this may sound a bit overwhelming and grim at times, being here is fascinating, rich, and often quite fun. This morning on my run I smiled as I was passed by a boda-boda (motorcycle) with one driver and 4 small children on the seat. They were dressed in school uniforms and smiling, clinging to one another on their way to school. The countryside is beautiful and I have had quiet evenings to read medicine or unwind. I am happy to be here and am so grateful for the experience.